Comprehensive Regional Approach to the Chronic Renal Failure Problem

COMPREHENSIVE REGIONAL APPROACH TO THE CHRONIC RENAL FAILURE PROBLEM FRED L. SHAPIRO, M.D.* Introduction Although chronicintermittenthemodialysis and renalhomotransplantation have been effective forms oftreatment for several years, most patients with end-stage renal disease are allowed to die without the opportunity of receiving either ofthese treatments. An even more distressing fact is that most patients with advanced chronic renal failure are not even given the benefit ofa trial ofappropriate medical management prior to their death. This includes the use ofthe newer renal diets, proper control offluid and electrolyte balance, appropriate blood-pressure regulation, treatment of infection and control ofcongestive heart failure. Whenthe individualwith end-stage renaldisease canno longer be maintained by conservative management, hemodialysis and renal transplantation offer him another chance of life—an opportunity to regain a near normal state ofhealth and activity. Both treatments are complicated and require specializedknowledge, training, and facilities. Theyare demanding of the medical staff and are very extravagant with personnel time and money. Dialysis and transplantation patients may develop medical problems and complications which are seldom "routine" and usually require extensive study and investigation to define the problem before appropriate treatment can be instituted. Nevertheless, the favorable clinical results achieved so far with hemodialysis and transplantation are convincing support for the wider application of these lifesaving techniques. In this paper various aspects ofchronic hemodialysis, particularly pertaining to the many problems encountered in applying the treatment and thesolutionswhichwehavefoundtobeacceptable to afew ofthemultiple dilemmas and problems, will be discussed. * Department of Internal Medicine, Hennepin County General Hospital, Fifth and Portland South, Minneapolis, Minnesota 55415. 597 NEED FOR TREATMENT Reliable statistics are not available, but it is estimated that between 35,000 and 55,000 patients die of chronic renal failure each year in the United States. Accurate vital statistics are available in Sweden where the incidence is about fifty-five people per million population per year dying of renal failure. Various reports estimate that from 20 to 50 percent of patients dying of chronic renal failure would significantly benefit from treatment with renal transplantation or dialysis. The potential patient load is dependent upon numerous factors, including available facilities, personnel , money, education both ofthe lay public and physicians, the selection criteria utilized, and where the patients live. In reality, most patients with end-stage renal disease could benefit to some extent from dialytic therapy iffacilities, personnel, and money were available. In 1969 approximately 3,000 patients in the United States were being treated by hemodialysis after ten years ofexperience with this treatment. A similar number of patients have received transplants over the past six years, so that there still remains considerable disparity between need and applied therapy. The reasons for the appallingly slow rate ofapplication of this lifesaving technique include insufficient numbers offacilities, lack of trained personnel, and most important, the lack offinancial support. Another major factor is a reluctance on the part of many nephrologists to devote the necessary time and effort to dialysis-related activities and associated problems. These physiciansjustifiably prefer to spend more time practicing clinical nephrology, teaching, and performing research. Our Program In an attempt to find a more tolerable answer to the marked disparity between need for treatment and available facilities, we have developed a regional program during the past three years designed to provide treatment for patients dying ofkidney failure. The program utilizes conservative medical management for as long as is reasonable. When medical management can no longer maintain the patient, then dialysis or a kidney transplant is made available. Our chronic dialysis program is unique in that dialysis treatments are performed in several different locations, including the parent center at Hennepin County General Hospital (HCGH), the patient's own home, in small satellite units in private hospitals throughout the region [1] and in a recently opened large twenty-bed chronic dialysis 598 nem Fred L. Shapiro · Chronic Renal Failure Proble, Perspectives in Biology and Medicine · Summer 1970 facility located in a small rehabilitation hospital one mile from the parent center [2]. This facility will be referred to as the MRU (Metropolitan Rehabilitation Unit). These several methods ofproviding dialysis are integrated with each other and also serve as maintenance and back-up facilities for a renal homotransplantation program. The parent center located...